27 January 2016
NHS 111 Call Handlers Failed to Identify Deadly Illness
The death of a baby boy from sepsis has highlighted doubts about whether NHS 111 call- handlers are able to identify serious illnesses in children.
One-year-old William Mead from Cornwall died in December 2014. At the time, his death was attributed to natural causes but a coroner’s inquest held in June last year found that he had died from septicaemia caused by a chest infection.
An NHS England report on the tragedy has found that William’s death could have been prevented had out-of-hours NHS helpline staff, who are not medically trained, recognised the life-threatening seriousness of his condition at the time.
Sepsis is a bacterial infection of the blood that occurs when the body’s immune system goes into overdrive whilst battling infection in any part of the body. It can set off a series of reactions that include widespread inflammation and a significant drop in blood pressure, meaning blood supply to vital organs such as the heart, brain and kidneys is reduced. If left untreated, sepsis can lead to multiple organ failure, shock, and eventual death.
Every year in the UK, around 100,000 people are admitted to hospital with sepsis. An estimated 37,000 people will die as a result of the condition.
In the months leading up to his death, William’s mother had taken him to his GP six times regarding his long-standing chest infection but was repeatedly told “not to worry.” When she telephoned the NHS non-emergency number shortly before William died, 111 call-handlers said: “It’s nothing serious.”
The NHS report into William’s death suggests that had a doctor taken the final call instead of 111 staff they would have recognised the need for “urgent medical attention.” It also highlights how his GP failed to recognise pneumonia, and details a total of 16 occasions when opportunities to save William’s life were missed. They include:
- inadequate advice given to William’s parents on what action to take in the event his condition deteriorated;
- the out-of-hours GP service had no access to William’s primary care records;
- the severity of William’s symptoms were not identified;
- William’s GP failed to record all of the relevant information regarding his condition in his notes;
- the pathway tool used by NHS 111 call-handlers was too basic to identify ‘red flag’ symptoms indicating sepsis.
The report concluded that, "Had any of these different courses of action been taken, William would probably have survived."
Sepsis mainly affects the very young and the very old but it can also affect anyone of any age, it doesn’t discriminate. Unfortunately, it is often difficult for both parents and health professionals to diagnose and, as a result, it is often overlooked or misdiagnosed.
As this horribly tragic case so poignantly illustrates, it is vital that NHS 111 call advisors receive training on how to recognise when to probe patients for more details about potentially life-threatening conditions so they know when to refer cases upwards. It is equally important that there is more awareness and better recognition of sepsis symptoms such as fever, breathlessness and discoloured skin, amongst parents and GPs.
The failure to recognise and manage sepsis is something Slater and Gordon’s clinical negligence solicitors see a great deal of in many of our most serious cases, particularly when patients are admitted to hospital over the weekend.
Unfortunately, the management of sepsis in hospitals often falls below acceptable standards and without a continued emphasis on raising awareness and improving the care of patients with sepsis, the number of errors made in failing to identify and treat the disease early is likely to continue.
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